The Evidence and Background for Supported Self-Management and Patient Activation

What is the history of Supported Self-Management in the NHS?

The value of supporting people to self-management effectively is well-established and has been a part of the literature in the health space for over three decades. It originated in the USA in the 1990’s at Stanford as the Chronic Disease Self-Management Programme [1], was introduced to the UK as the Expert Programme in 2002 [2], and was central to the Health Foundation’s Co-Creating Health Programme (2007-2012)[3] which aimed to embed self-management support directly into mainstream UK healthcare.

A report in 2011 by the Health Foundation “Helping people help themselves” [4] reviewed the evidence to date and considered “whether it is worthwhile to support self-management”.  It concluded that “the UK healthcare system can’t afford to ignore the evidence” and that “reducing people’s dependence on health professionals and increasing their sense of control and wellbeing is a more intelligent and effective way of working”. At the same time, it stated that, in 2011, self-management support was “still in its infancy” and that “some approaches are significantly more effective than others”.

Since then, we’ve seen Supported Self-Management become a feature of NHS policy in the form of condition-specific education programmes, clinician training in coaching skills and, more recently, in 2020, the introduction of Health and Wellbeing Coaches specially trained to support self-management [5]. It is central to the current NHS Personalised Care Model [6] and has a key role to play in ‘prevention’, one of the three pillars set out in the 2025 NHS 10-year plan [7].

Evaluation of different Supported Self-Management interventions and approaches is, however, still a work in progress – establishing which interventions or approaches work best in achieving the aims.

What does ‘patient activation’ have to do with supported self-management?

‘Patient activation’ is a developmental concept that defines where people need to be in order to effectively manage their own health[8]. It identifies four stages of ‘activation’:

(1) believing the patient role is important, (2) having the confidence and knowledge necessary to take action, (3) actually taking action to maintain and improve one's health, and (4) staying the course even under stress.

A ‘patient activation’ questionnaire is a questionnaire that measures people’s levels of knowledge, skills and confidence to self-manage effectively.

‘Self-efficacy’ or ‘self-management’ questionnaires can perform a similar function, identifiable by the type of questions being asked of the individual:

“I know….” (knowledge); “I’m confident that I can…(confidence and skills)”.

Note: this is different from a ‘wellbeing' questionnaire which is focused more on how people are feeling, or an ‘opinion’ questionnaire which is focused more on views or beliefs.

Taken at the beginning and end of a coaching intervention, a patient activation (or self-efficacy or self-management) questionnaire is therefore a helpful tool to assess the effectiveness of that individual intervention or approach in improving people’s knowledge, skills and confidence to self-manage effectively.

Used as a comparative tool and across populations, patient activation measures can help to evaluate which approaches are most effective in achieving the aim of supporting self-management:

Improving outcomes for individuals and reducing unnecessary reliance on (and therefore costs to) health services.

Why are patient activation questionnaires a key tool in establishing whether interventions or approaches are achieving the aims of supporting self-management?

Apart from providing a means of evaluating individual interventions or approaches, a direct link has been demonstrated between people’s ‘activation’ scores and their use of health services:

  • When patient activation levels change, health outcomes and costs change too (Greene et al, 2015)[9]

  • Self-management capability in patients with long-term conditions is associated with reduced health care utilisation across a whole health economy: cross-sectional analysis of electronic health records (Barker et al, 2018)[10]

  • How is patient activation related to healthcare service utilisation? Evidence from electronic patient records in England (Bu et al, 2021) [11]

It’s important to highlight that the reduced reliance on clinical services in this context isn’t due to simply being redirected to other services or a lack of access to clinical services, but due to a reduced need for clinical services due to increased knowledge, skills and confidence to self-manage (i.e. higher activation scores). This can be further demonstrated by correlating increased activation scores with improved quantitative (e.g. measurable clinical) and/or qualitative (e.g. patient reported) data.

For instance, any intervention that increases people’s activation levels may be expected to be reflected in improvements in outcomes and reduced reliance on clinical services. This correlation was demonstrated in the recent evaluation co-authored by Know Your Own Health and Imperial College London.[12]

Therefore, ‘patient activation’ is potentially the primary Key Performance Indicator for interventions or approaches that are designed to support self-management. Used as an evaluation tool in this way, it also provides a basis for effective cost-benefit analyses to be carried out on these interventions across populations.

What sort of interventions can support people to build their knowledge, skills and confidence to self-manage effectively?

NHS England describe three interventions for supporting self-management [ref: https://www.england.nhs.uk/personalisedcare/supported-self-management/]:

  • Peer Support (Group support with people with lived experience)

  • Self-Management Education (Condition- or issue-specific education and support)

  • Health Coaching (Aimed specifically at supporting self-management and patient activation through the use of coaching skills to help people to set achievable goals)

Health Coaching to support self-management and patient activation is:

  • Non-clinical

  • Non-directive

  • Non-judgmental

Health & Wellbeing Coaches working in the NHS are not required to have any specialist knowledge as the role is non-advisory and is focused solely on coaching skills, as set out in the Personalised Care Institute’s Core Curriculum Health Coaching skills aimed at supporting self-management and patient activation.

Health Coaching models, frameworks and approaches

All Health and Wellbeing Coaches working in the NHS are required to complete a PCI-accredited training in Core Curriculum skills for Health Coaching. However, the models or frameworks used to deliver Health Coaching as an intervention may vary.

StACC, as used by Know Your Own Health and described in the ‘StACC’ section, is one model.

Examples of other models and frameworks being used in the NHS are:

GROW/TGROW: GROW/TGROW is a coaching conversation model that is similar to StACC in that it uses much the same toolkit of skills, and shares similar principles and components. The main difference is in terms of its original aims and how those are reflected in how it is structured and implemented, i.e. it was designed for performance management rather than supporting self-management and increasing activation.

COM-B: In contrast to StACC and TGROW, COM-B isn’t a coaching conversation model as such, but works as a framework for understanding what needs to be in place for behaviour change to occur.

Behaviour Change is closely linked to Supported Self-Management and Patient Activation as becoming effective self-managers often involves changing certain behaviours, especially relating to lifestyle behaviours. Behaviour change, where appropriate, is therefore one of the aims of coaching conversations to support self-management.

MOTIVATIONAL INTERVIEWING (MI): Designed originally to help people with addiction and substance use problems, MI is used to support behaviour change. Supported self-management coaching approaches share elements of Motivational Interviewing.

TRANS-THEORETICAL MODEL (TTM): Similar to patient activation but focused on behaviour change as opposed to confidence to self-manage, the Transtheoretical Model, describes the stages that people move through when changing behaviours.

Know Your Own Health’s outcomes platform is able to support any model, framework, or approach. This enables coaches, their managers and commissioners to gather more evidence around what works best for which cohorts of patients and enables researchers to carry out wider cost-benefit analyses for the benefit of patients, the NHS and other public services.

Links

  1. Stanford’s Chronic Disease Self-Management Programme: https://selfmanagementresource.com/programs/small-group/chronic-disease-self-management-small-group/

  2. The Expert Patients Programme: https://www.gov.uk/government/case-studies/the-expert-patients-programme

  3. The Health Foundation’s Co-Creating Health Programme (2007-2012): https://www.health.org.uk/funding-and-partnerships/programmes/co-creating-health

  4. De Silva D. Helping people help themselves – A review of the evidence considering whether it is worthwhile to support self-­management. London: The Health Foundation, 2011: https://www.health.org.uk/sites/default/files/HelpingPeopleHelpThemselves.pdf

  5. NHS England: Health and Wellbeing Coaches: https://www.england.nhs.uk/personalisedcare/workforce-and-training/health-and-wellbeing-coaches/

  6. NHS England: Comprehensive Model of Personalised Care: https://www.england.nhs.uk/personalisedcare/comprehensive-model-of-personalised-care/

  7. NHS England “Fit for the Future: 10 Year Health Plan for England”: https://www.england.nhs.uk/long-term-plan/

  8. Hibbard et al (2004). Development of the Patient Activation Measure (PAM): conceptualising and measuring activation in patients and consumers: https://pubmed.ncbi.nlm.nih.gov/15230939/

  9. Greene et al, 2015. When patient activation levels change, health outcomes and costs change too: https://pubmed.ncbi.nlm.nih.gov/15230939/

  10. Barker et al, 2018. Self-management capability in patients with long-term conditions is associated with reduced healthcare utilisation across a whole health economy: cross-sectional analysis of electronic health records: https://qualitysafety.bmj.com/content/27/12/989

  11. Bu and Fancourt, 2021. How is patient activation related to healthcare service utilisation? Evidence from electronic patient records in England: https://pubmed.ncbi.nlm.nih.gov/34736441/

  12. Henry et al, 2015. Health coaching for people with long-term conditions and multimorbidity: a mixed methods prospective service evaluation of Structured Agenda-free Coaching Conversations (StACC) in UK primary care: https://link.springer.com/article/10.1186/s12889-025-23535-0